ADDRESSING VACCINE HESITANCY - PolicyLab
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POLICYLAB
E V I D E N C E TO A C T I O N B R I E F | S P R I N G 20 17
ADDRESSING
VACCINE HESITANCY
TO PROTECT CHIL DREN & COMMUNITIES
AGAINST PRE VENTABL E DISE A SES
Bardia Nabet, Jennifer Gable, Jennifer Eder, Kristen Feemster | policylab.chop.edu
P R O D U C E D I N C O L L A B O R AT I O N W I T H T H E VA C C I N E E D U C AT I O N C E N T E R
CONTENTS EXECUTIVE SUMMARY
Vaccines have successfully
2 eliminated or dramatically
E X EC U T I V E S UM M A R Y
reduced the incidence of many
infectious diseases in the United
States. Routine immunization of
4
B AC KG RO U N D all children born in one year can:1
• Save 42,000 lives,
6 • Prevent 20 million cases
P RO B L E M
of disease,
• Reduce direct health care
10 costs by $13.5 billion and
W H AT W E C A N D O
• Save $68.8 billion in total
societal costs.
16
C O N C LUS I O N
Despite availability and routine recommendation of these vaccines,
approximately 42,000 adults and 300 children in the United
States still die each year from vaccine-preventable diseases.2
While ongoing vaccination programs help to keep these diseases at
bay, some vaccine-preventable diseases have been re-emerging.
For instance, The Centers for Disease Control and Prevention (CDC)
declared measles eliminated from the U.S. in 2000, but reported 667
cases in 27 states in 2014.3 Although measles is no longer endemic
to the U.S., it is still easily imported by travelers exposed in other
countries and then quickly spread. Recent pertussis (whooping
cough) rates also greatly exceed those that the U.S. maintained
during the 1990s and early 2000s, rising from approximately 7,800
cases in 2000 to nearly 33,000 in 2014.4 The CDC reported that most
of these cases affected unvaccinated or undervaccinated children.5
Children are considered undervaccinated if they are missing at least
one vaccine by the appropriate age as recommended by the CDC’s
Advisory Committee on Immunization Practices (ACIP).6,7
2 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASES
Figure 1
ESTIMATED MMR VACCINATION COVERAGE AMONG
CHILDREN ENROLLED IN KINDERGARTEN, 2015–2016
RI
CT
NJ
DE
MD
DC
○ States at or above 95% ○ States between 90–94.9% ○ States below 90%
Source: Centers for Disease Control and Prevention. SchoolVaxView: 2015–16 School Year Vaccination Coverage Reports. October 2016.
A rise in vaccine hesitancy—a behavior Healthy People 2020—a national health
influenced by lack of trust in the medical promotion and disease prevention initiative
community, concerns about vaccine safety, of the U.S. Department of Health and Human
efficacy, necessity or convenience and other Services (HHS)—established target vaccination
issues related to vaccination—has contributed rates for each vaccine-preventable disease that
to undervaccination through parental decisions are necessary to achieve herd immunity and
to delay or refuse vaccines for their children. protect entire communities. Some childhood
A parent’s decision not to vaccinate his or her vaccines, such as measles, mumps and rubella
child puts not only that child, but every person (MMR), diphtheria, tetanus and pertussis
that child comes into contact with at increased (DTaP) and varicella (chicken pox), have a target
risk of infection. As more parents choose not vaccination rate of 95%, and many states and
to vaccinate, overall vaccination rates decline. communities are failing to reach these goals.8
Lower rates of vaccination increase the risk of
preventable disease outbreaks by compromising This PolicyLab Evidence to Action brief
herd immunity, a safe vaccination rate that can summarizes research findings around the
significantly reduce the spread of infectious disease causes and effects of vaccine hesitancy, and
within a community. proposes policy changes that could lead to
increased vaccination rates and greater protection
for the current and future health of our children.
EVIDENCE TO ACTION BRIEF | SPRING 2017 3
BACKGROUND
Vaccination programs have a long history of significantly reducing the prevalence of vaccine-
preventable diseases. A vaccine successfully eradicated smallpox worldwide in 1977.9 The U.S.
declared the national elimination of polio and measles in 197910 and 200011, respectively. The
prevalence of other preventable diseases, such as diphtheria and rubella, has reached such low
levels that most Americans have never experienced or witnessed them.12
This success, however, requires sustained and sufficiently high
vaccination rates. Unfortunately, a rising level of vaccine hesitancy
has begun to threaten the herd immunity that makes the success
The shift of vaccination programs possible. A 2013 study of more than
toward intentional 300,000 U.S. children found that approximately 49% of children
born between 2004 and 2008 were undervaccinated—or hadn’t
vaccine delay and completed all recommended vaccinations by the recommended
age—at some time prior to their second birthday, and one in eight of
refusal is directly those children were undervaccinated because of parental choice to
delay or refuse certain vaccines.13
associated
The shift toward intentional vaccine delay and refusal is directly
with increased associated with increased occurrence of preventable diseases
occurrence of for individuals and entire communities. For instance,14 although
the U.S. declared measles eliminated in 2000 and it is no longer
preventable endemic in this country, the disease is extremely contagious and
can be easily imported when individuals enter the U.S. after having
diseases for been exposed in other countries. Since 2000, more than 1,500
measles cases have been reported, and 2014 saw the highest number
individuals of cases in two decades. That year, a high-profi le measles outbreak
and entire that originated in a California Disney theme park was associated
with 111 cases that spread to several states. Approximately half of
communities. those who contracted measles were known to be unvaccinated, the
vaccination status of more than 40% of the others was unknown or
undocumented and most were old enough to receive the vaccine but
remained unvaccinated by parental choice.12,14
4 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESFigure 2
MEASLES INCIDENCE BEFORE AND AFTER MMR
VACCINE INTRODUCTION: 1953–2014
MMR
INTRODUCED
IN 1963
800,000
2004–2014
600,000 700
600
500
400
300
400,000
200
100
0
200,000
0
1954 1964 1974 1984 1994 2004 2014
Measles Cases 1954–2003 Measles Cases 2004–2014
Source: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition.
Appendix E-1: Reported Cases and Deaths from Vaccine Preventable Diseases, United States, 1950–2013; 2015.
Local vaccination rates can vary greatly even within states that
have high overall vaccination rates. In addition to individual risk
of exposure from contact with an unvaccinated person, geographical
clustering of intentionally unvaccinated children puts whole
communities at increased risk by decreasing protective herd
immunity for a specific region.8 One way of measuring this shift
is through the rise in the number of families choosing to receive
vaccine exemptions rather than immunizing their children according
to school immunization requirements. For instance, in 2010, public
school vaccine exemption rates at the county level in Pennsylvania
ranged from 0.1% to 5.5%. For all schools in Washington state that
year, exemption rates ranged from 1.0% to 25.3%.15 Research has
shown that areas with clusters of vaccine exemptions, where many
parents intentionally choose not to vaccinate their children, are
significantly more likely to experience outbreaks of pertussis.16
EVIDENCE TO ACTION BRIEF | SPRING 2017 5PROBLEM
Public health entities such as the World Diminished Prioritization of Vaccination
Health Organization and the National
17
Lack of Confidence in Safety and Efficacy
Vaccine Advisory Committee18 have focused
on better defining vaccine hesitancy to help Inadequate State Policies
inform interventions designed to address
it. Based largely upon this body of work, we
have identified three primary contributors
to vaccine hesitancy and its ability to
negatively impact children’s and population
health in the United States.
Diminished Prioritization of Vaccination
Vaccines are victims of their own success. Many educated and already have at least one other
parents today have never seen a case of measles, child.20 These delays may not be driven by negative
mumps, whooping cough or bacterial meningitis. attitudes toward vaccines, but demonstrate that
Lack of first-hand experience with vaccine- barriers to accessing vaccines combined with an
preventable diseases can lower parents’ perception underappreciation of the severity and prevalence
of the likelihood and severity of infection, leading of preventable diseases can keep children from
to the belief that vaccination is not necessary being fully vaccinated on time.
to protect children’s health.19 This can lead
parents who may have no particular objections to Late vaccine initiation can also be due to a parent’s
vaccination to keep their children unvaccinated as deliberate decision to delay vaccination. The
a matter of convenience, particularly if they face combination of diminished perception of risk
any barriers to accessing vaccine services. with rising public concerns about vaccine safety
can make delaying or refusing vaccination seem
Delaying the earliest recommended vaccinations like a prudent decision for some parents trying to
is risky because it can disrupt the entire protect their children’s health.21 Instead, in some
vaccination schedule, leaving infants and young cases, delaying a vaccine beyond the recommended
children unprotected from preventable illnesses age may increase the risk of uncommon potential
for longer periods of time and when they are at vaccine side effects. For instance, one study
highest risk for severe morbidity or even death showed an increased risk of seizure associated
from vaccine-preventable diseases. A 2009 with high fever after delayed receipt of a vaccine.
study of newborns from a large urban setting More importantly, the decision to delay increases
found that children most at risk of late vaccine the amount of time a child is at risk of contracting
initiation are those whose mothers attend fewer a vaccine-preventable disease.22,23
prenatal care visits and who are younger, less
6 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESLack of Confidence in Safety and Efficacy
The success of vaccination programs at reducing the prevalence of preventable illness has lowered some
parents’ perception of the risks associated with those illnesses. When parents do not see the potential
benefit of vaccination, any perceived safety concerns about a specific vaccine may seem like a greater risk
than the infection itself. Such vaccine safety concerns are also fueled by a prominent anti-vaccination
movement in the U.S., which instills a lack of confidence in important vaccine programs. This movement is
dangerous largely because it is:
Based on misinformation. all, misrepresent truthful sources, use outdated
Some of the more common arguments or disproven information and rely on anecdotes
against vaccination include misleading that can be compelling.30
and unsubstantiated claims about vaccine
Anti-vaccine groups have also run TV public
safety. These include claims that vaccines
service announcements (PSAs) in localities
contain poisons, cause autoimmune or
where lawmakers have considered stronger
neurodevelopmental disorders or can overwhelm
vaccination requirements. These PSAs use
the immune system. A significant contributor
messages that may be emotionally compelling,
to decreasing confidence in vaccines was a
but that are typically based on unsubstantiated
falsified and later discredited study in 1998 that
rhetoric rather than the evidence or
incorrectly linked the MMR vaccine to autism.
recommendations from the medical community.
Although the journal retracted the article and
the lead researcher lost his medical license and Vaccine laws are often politicized, and research
was found guilty of ethical, medical and scientific has shown that when the media heavily
misconduct,24 it created safety concerns for the covers such controversies around mandatory
public that have continued to resonate. vaccination, public support for vaccine
programs and trust in physicians can decrease.
Multiple studies since this 1998 article have found
But when the vaccine-related coverage does not
no connection between vaccines and autism, and
emphasize political conflict, it can potentially
yet this same researcher created a documentary
increase support for immunization programs.31
in 2016 that continues to assert this claim.
Experts discredit the documentary as a deceptive
conspiracy theory.25,26 Unfortunately, the Difficult to reverse.
perpetuation of this myth can still further vaccine The scientific community has struggled
hesitancy and threaten the health of entire to effectively communicate evidence that
communities. For parents trying to understand a supports vaccine safety and efficacy in the
child’s diagnosis of a condition like autism, false face of anti-vaccine rhetoric. The primary
but compelling stories linked to vaccines can emphasis of vaccine education has centered
continue to influence their decisions. on dispelling myths about adverse effects,
such as the inaccurate link to autism and other
Perpetuated in the media and online. unfounded safety concerns. It is difficult,
however, to eliminate the bias created by the
More than half of internet users report that
original misinformation, especially when it is
their medical decisions are often influenced
tied to a compelling story. In fact, the repetition
by internet searches.27,28 This reliance on the
of inaccurate information during attempts
internet, where information can be shared
to refute it can have an unintended “backfire
with no filter or review, makes it more likely
effect”—increasing familiarity with and
that vaccination decisions are based on
perpetuating the myth,29,32 further driving
misleading information.29 Anti-vaccination
down vaccine acceptance. It is important to
messaging occurs more on the internet than any
promote accurate information, but the challenge
other media outlet. Anti-vaccination websites
is doing so without inadvertently furthering the
often self-reference or include no reference at
negative effects of the original false claims.
EVIDENCE TO ACTION BRIEF | SPRING 2017 7Inadequate State Vaccine Policies
Every state mandates that children receive no additional review. Others require parents to
vaccinations prior to enrolling in school. take additional steps such as having a health care
The U.S. Supreme Court has established the provider sign their exemption form indicating
constitutionality of mandatory vaccination, that they received education about vaccines and
including for school entry. The first case in 1905, understand the risks of not vaccinating.37,38
Jacobson v United States, upheld a Massachusetts
law requiring adults over age 21 to be immunized State exemption policies can significantly limit
against smallpox in the interest of the public’s the reach of immunization programs. Evidence
health and safety. In 1922, Zucht v King upheld a shows that the availability and ease of nonmedical
local government mandate for vaccination as a exemptions increase exemption rates and
prerequisite for attending public school. As a result, decrease vaccination rates.19 Lower vaccination
state and local municipalities can formulate their rates subsequently increase the level of risk for
own immunization requirements, including the outbreaks of preventable diseases. For instance,
type of vaccines required, available exemptions and between 1986 and 2004, pertussis incidence in
mechanisms used to enforce the requirements.33 states that allowed personal belief exemption
was more than twice as high as states that only
Every state allows medical exemptions for allowed medical and religious exemptions. In that
children with a contraindication to vaccination, same time period, pertussis rates were also 41%
such as a compromised immune system or allergy higher in states that accept parent signatures as
to the vaccine.34 Most states also allow nonmedical proof of their child’s immunization compliance
exemptions based on religious or personal beliefs. compared with states that required documentation
All but three states—West Virginia, Mississippi of immunity.39 Research from 2012 showed
and California—offer religious exemptions. nonmedical exemption rates were 2.3 times higher
Personal belief exemptions are less common, but in states with policies that make it easy to opt-out of
are available in 18 states.35,36 In general, parents immunization requirements.40
or guardians must provide documentation of a
medical contraindication from a physician or Vaccination rates also vary significantly by
get a nonmedical exemption in order for their region within states. Even states with low overall
unvaccinated child to attend school, but some exemption rates can have smaller geographic
states do not always enforce this rule. Additionally, clusters where large numbers of individuals
the process and requirements to receive a religious choose not to vaccinate, leading to a reduction
or personal belief exemption vary greatly. For in immunization rates below the herd immunity
instance, some states simply require parents to threshold. This type of spatial clustering increases
print out an exemption form online, indicate their the likelihood of disease outbreak within and
own reason for the exemption and submit it with beyond the immediate community.15
State exemption policies can significantly limit the reach of
immunization programs. Evidence shows that the availability
and ease of nonmedical exemptions increase exemption rates
and decrease vaccination rates.
8 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESFigure 3
STATE NON-MEDICAL EXEMPTIONS FROM SCHOOL IMMUNIZATION REQUIREMENTS, 2016
○ Religious AND Personal Belief Exemptions ○ Religious Exemptions ○ Nonmedical Exemptions Not Allowed
AR AZ CO ID LA ME MI MN MO ND
OH OK OR PA TX UT WA WI AK AL
CT DE FL GA HI IA IL IN KS KY
MA MD MT NC NE NH NJ NM NV NY
RI SC SD TN VA VT WY CA MS WV
*Washington, D.C. also allows Religious Exemptions.
Source: National Conference of State Legislatures. States with Religious and Philosophical Exemptions from School Immunization Laws. January 21, 2016; Retrieved from http://www.ncsl.org/
research/health/school-immunization-exemption-state-laws.aspx.
EVIDENCE TO ACTION BRIEF | SPRING 2017 9WHAT WE CAN DO
PolicyLab researchers Improve Health Care Providers’ Ability to Make
have developed a set of Strong Vaccine Recommendations
recommendations to address
Strengthen and Enforce Vaccine Mandates for School Entry
parents’ hesitancy about
vaccinations and strengthen Improve Public Vaccine Education, Awareness and Access
state vaccine policies to
optimize immunization rates.
Improve Health Care Providers’ Ability to Make Strong Vaccine Recommendations
A provider’s recommendation is one of the strongest efficacy by presenting evidence-based information in
predictors of a patient receiving a vaccine, and a way that is easy to understand and that effectively
positive recommendations can significantly improve addresses specific concerns. Providers should therefore
vaccination rates.41,42 Providers have the opportunity remain up-to-date on the latest information about
to address parental concerns that lead to vaccine vaccine safety and best practices, as well as prevalent
hesitancy and the dangers of refusing or delaying reasons for hesitancy, and be able to give a strong,
vaccination. They can respond to parents’ complacency effective recommendation.
toward vaccines or fears regarding their safety and
10 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESSome strategies to increase positive provider influence on vaccination outcomes Examples of Existing
include the following: Vaccine Education
Opportunities:
Health care educators should place a stronger emphasis on training about
vaccine safety, efficacy and communication at all levels of career development.
Opportunities to build these skills and expertise must be more readily available
in both medical and nursing schools and through continuing medical and nursing
The University of Pennsylvania
education. All health care providers need to provide a consistent message.
offers fourth-year medical
students an intensive one-week
Obstetricians should counsel mothers before giving birth about the course on vaccination. The course
importance of following the recommended vaccination schedule to make sure covers the science of vaccines, as
their infant will be fully protected. well as legal, political and social
Late initiation of immunizations makes children less likely to receive all issues related to vaccination,
vaccinations when they are recommended, and more likely to spend more time including how to effectively
unprotected from potentially devastating, preventable diseases. Research shows communicate with vaccine
that prenatal visits can positively impact health care outcomes such as on-time hesitant parents.43
vaccinations. A 2009 study found that attending fewer than five prenatal visits is
one of the greatest risk factors for infants starting vaccines late and for increasing
the amount of time before the first vaccination. Early interventions during
prenatal care may therefore be a key strategy to help prevent vaccine delays and
The CDC offers continuing
underimmunization. Some methods to get more pregnant mothers to attend
education opportunities on
prenatal visits and accomplish these interventions include improved provider
vaccination, including training
training and partnerships between obstetric practices and local maternal and
on how to improve vaccination
child health services that promote vaccine education within prenatal care.20
rates and increase the likelihood
Providers should aim to reduce or eliminate the number of patients on that parents will follow the
alternate vaccination schedules. recommended schedule for
children. Available courses also
Pediatric offices should inform all patients that the office follows the CDC- include materials that health care
recommended vaccine schedule and every parent is expected to have their educators can incorporate into
children fully vaccinated on time. Providers can use the following strategies to existing medical school curricula.44
manage relationships with parents who wish to refuse or delay vaccination:
• Address vaccine hesitancy through motivational interviewing, during which
providers actively elicit and acknowledge specific concerns from parents to
foster open and honest dialogue. The American Academy of
Pediatrics offers a free online
• Keep up-to-date with developments in vaccine safety and recommended course titled, “Challenging Cases:
practices, as well as prominent concerns being raised by the public. See Figure Vaccine Hesitancy,” which provides
4 for a list of talking points to address some of the most common concerns about strategies to discuss vaccination
vaccine safety and efficacy. with hesitant parents.45
• Request signed forms from parents who continue to refuse or delay vaccination,
and record informed refusal in their child’s medical records.46
• Reinforce the safety and efficacy of the vaccine schedule by personalizing its use.
Share stories about the successes of vaccines and personal choices to immunize
your own children or other family members.
• Maintain doctor–patient relationships with vaccine hesitant families to provide
an opportunity to build trust and confidence in a provider’s recommendation.
However, if repeated attempts fail to convince parents to vaccinate their children,
providers may consider dismissing families from the practice as an acceptable
option. While additional studies are needed, anecdotal evidence indicates that some
parents accept vaccines when faced with the choice of vaccination or dismissal.
Additionally, providers face a dilemma when their unimmunized patients can
potentially expose other patients to vaccine-preventable diseases. (C ON T. ➝)
EVIDENCE TO ACTION BRIEF | SPRING 2017 11Figure 4
TALKING POINTS TO ADDRESS VACCINE HESITANT PARENTS
Vaccines are safe. Infants experience Spreading out The recommended Delaying vaccines
They are tested the same amount vaccinations vaccine schedule increases the risk
in thousands of of stress during beyond the ensures the best of contracting
people before each visit, whether recommended immune response vaccine-
they are licensed they receive two schedule may and protection preventable
and are monitored or five shots at be less safe when a child is most diseases and
extensively after once. Therefore, and effective. at risk of infection. infecting others.
being made available spreading out the
to the public. shots over more
visits may be more
stressful.
The American Academy of Pediatrics (AAP) assessments of vaccination coverage to find gaps
supports the dismissal of a family that refuses and disparities, and facilitate management and
to vaccinate, but asserts that it must be done in accountability of vaccination programs. Increasing
keeping with state laws, which typically include participation in IIS among all providers will help to
sufficient notice, continuing care for at least 30 realize the full potential benefits of these systems.49
days, ensuring that alternative providers are
available and offering families information to help
States should require third-party payers to provide
find another physician.47
adequate reimbursement to providers for the full
These methods may help providers maintain cost of vaccination services.
constructive relationships with families in their Federal law requires that insurers cover
care, and also successfully increase vaccine recommended vaccinations at no cost to the
acceptance to ensure that their patients remain on patient, but providers are not always adequately
the recommended vaccination schedule. reimbursed. States should require payers to
reimburse providers for the costs of purchasing,
storing and administering vaccinations to their
States should help to strengthen immunization
patients. Furthermore, successfully recommending
information systems (IIS) by requiring all providers
vaccinations to hesitant parents can involve lengthy
who administer vaccines to report doses for
conversations. The National Vaccine Advisory
children, adolescents and adults.
Committee recommends the development of
Nearly all states currently operate IIS—electronic billing codes to allow physicians to be compensated
databases that record all immunization doses—but for counseling parents on the importance of
their regulation and actual utilization vary by getting vaccines for their children, even if the
state.48 The Community Preventive Services Task parents eventually choose not to vaccinate. The
Force, an independent panel of public health and Committee’s recommendations also suggest
prevention experts, recommends IIS due to strong establishing pay-for-performance initiatives, which
evidence that they are successful in increasing could be measured by achieving a minimum vaccine
vaccination rates and reducing vaccine preventable coverage goal and continuing to improve on vaccine
disease. For providers, IIS can help to determine coverage rates.18 These measures could eliminate
patients’ vaccination status and offer reminder and any fi nancial disincentives facing providers and
recall tools. For communities, these systems can support their ability to make strong and consistent
guide public health responses to outbreaks, inform vaccine recommendations.
12 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESStrengthen and Enforce Vaccine Mandates for School Entry
Vaccine mandates for school entry can help to increase immunization rates, but they are only effective
when they are meaningful and enforceable. Laws and regulations regarding vaccine requirements
and exemptions are established at the state level. States should consider tailoring any of the following
strategies to strengthen and build upon their existing mandates:
Pass legislation to eliminate nonmedical Some states require parents to receive
vaccine exemptions for entry to both public education on the benefits of vaccines, be
and private school. counseled by a physician on their decision to
The American Medical Association and exempt their child or sign an affidavit stating
AAP released policy recommendations in their reasons for opting out before granting
June 2015 and August 2016, respectively, a nonmedical exemption.52 For instance, in
encouraging state legislatures to eliminate 2010, Washington had the highest vaccine
all nonmedical exemptions.50,51 Currently, exemption rate in the country at 6.2%. Most of
only three states—California, Mississippi those exemptions were nonmedical.53 In 2011,
and West Virginia—do not allow any type the state was part of one of the largest measles
of nonmedical exemption for school entry. outbreak in recent history, and in response,
Mississippi has one of the strongest and passed a tougher exemption law that requires
longest-standing vaccine policies in the proof that a physician counseled the parent
country, in place since 1972, which has on the risks and benefits of immunization.
resulted in the highest vaccination and lowest Religious and personal belief exemption rates
exemption rates. In the 2014–2015 school decreased to 3.5% by the 2014–2015 school year.
year, more than 99.2% of kindergartners
in Mississippi received the MMR, varicella Establish nonmedical vaccine exemption fees.
(chicken pox) and DTaP (diphtheria, tetanus
Parents who choose not to vaccinate their
and pertussis) vaccines, compared to national
children for nonmedical reasons impose the
averages around 94%. Only 17 Mississippi
additional risk of contracting a preventable
kindergartners, less than 0.1%, had a vaccine
disease not only on their child, but also on the
exemption, compared to the national average
entire community. The cost of this decision
of 1.7%.8 In 2015, California became the most
on society includes the increased risk for
recent state to remove religious and personal
outbreaks, the economic costs associated
belief vaccine exemptions and require parents
with managing a potential outbreak and
who refuse to immunize their children to
the administrative cost of processing and
utilize homeschooling.36
documenting the exemption. Imposing
fees for each vaccine exemption shares
Use regulatory measures to make the the financial burden with those who are
exemption process more rigorous. contributing to potential societal costs, in
Stricter exemption rules that require parents addition to serving as a financial disincentive
to prove that they are making informed for vaccine refusal. Revenue from such fees
decisions based on legitimate medical could contribute to vaccination-related
contraindications or strong personal or efforts, including management of outbreaks
religious conviction could deter parents and vaccine education.54
who seek exemptions due to inconvenient
access to immunization services or mild
vaccine hesitancy. A 2015 study found that
the additional step of requiring physician
signatures or state health department Parents who choose not to vaccinate their
approval for nonmedical exemption
applications was associated with lowering children for nonmedical reasons impose the
exemption rates. These more effective
exemption policies also correlated with
additional risk of contracting a preventable
lower incidence of pertussis.52 disease not only on their child, but also on
the entire community.
EVIDENCE TO ACTION BRIEF | SPRING 2017 13Improve Public Vaccine Education, Awareness and Access
To combat the spread of misinformation and complacency that keep
parents from having their children vaccinated, it is important to ensure
that parents understand that the benefits of vaccination outweigh any
perceived risk or inconvenience. The following strategies can be used to
improve public knowledge of and access to recommended vaccines:
States and local health departments should invest in public
awareness campaigns to promote the benefits of vaccination
and risks of refusal and delay.
Parents choose not to vaccinate their children for a variety of reasons,
ranging from deeply held personal objections to fears of potential harm
to simply avoiding what they see as an unnecessary inconvenience.
Health departments should research and implement the most effective
Example of a Public communication strategies, making sure to target their messaging to reach
Awareness Campaign: each type of vaccine hesitant parent and address their specific needs and
concerns. This effective use of social marketing practices can help to
establish social norms about vaccines and increase their acceptability.55
For instance, a 2014 study found that attempts to correct myths about
vaccine safety risks were ineffective at changing parents’ existing
Every Child By Two (ECBT) is a negative attitudes toward vaccination. Interventions that used an
nonprofit organization that uses alternative narrative highlighting the health risks associated with
a variety of public education not vaccinating children, such as a mother’s account of her child
campaigns to increase awareness contracting measles and photos of infected children, showed more
of the importance of timely promise in increasing vaccine acceptance.56 The framing of messages
vaccination. Its messaging used to combat false claims about vaccinations is a potential area for
materials, which have included improvement to help increase vaccination rates, but much is left to be
billboard campaigns, social media learned about how to successfully increase positive beliefs in the midst
marketing, public education of growing anti-vaccine sentiment. We should partner with experts
events and PSAs, are designed in health behavior and communication to establish best practices to
to direct viewers to credible target key beliefs that influence these important health care decisions.
vaccine information sources.
ECBT’s prominent Vaccinate Your
Baby campaign, which utilized Federal legislation should allow payers to offer lower-cost health
these communication tools, insurance premiums based on vaccination status.
reinforced the safety of vaccines Federal law already allows premium differentials for a limited set
and highlighted the dangers of of factors, such as rewarding individuals who abstain from or quit
vaccine refusal and delay through smoking with lower insurance premiums.58 Legislators could add
personal stories. This campaign vaccination status to this list. The inclusion of this benefit can act as a
generated significant coverage financial incentive to follow recommended immunization schedules
from news outlets and acted as a for parents with no serious concerns about vaccine safety and reinforce
strong counterargument to the the safety and importance of vaccine programs for those who remain
anti-vaccine movement.57 hesitant. Strong immunization information systems as recommended
by the Community Preventive Services Task Force could support the
implementation of this type of premium differential.
14 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESStates should make vaccines more accessible States should increase pharmacists’ ability
to children by allowing school-based health to recommend and administer vaccines to
clinics to administer them. patients of all ages.
Offering vaccinations in the school setting is Many parents interact with pharmacists on a
an opportunity to provide legitimate vaccine more regular basis than with a primary health
education and boost immunization rates by care provider. It is important, therefore, that
taking the vaccines directly to the children.59 pharmacy schools train future pharmacists
For instance, Rhode Island’s Vaccinate Before to counsel patients on vaccine decisions,
You Graduate program provides middle and including how to provide information about
high school students with any recommended vaccine benefits and counter inaccurate
vaccine to ensure that every student is fully statements about vaccine risks.61 Additionally,
protected by the time they graduate. In the allowing pharmacists to provide vaccines,
2014–2015 school year, nearly 9,000 students such as the influenza vaccine, in a location
were vaccinated through this program.60 that is often more convenient than a
providers’ office has been shown to increase
immunization rates.62
As of July 2016, 48 states allow pharmacists
to administer any type of vaccine. Some of
these states, however, impose barriers to
vaccination in pharmacies related to age,
vaccine type and prescriptions. Additionally,
28 states and territories allow pharmacists
to vaccinate children of any age, while some
limit this option to particular types of
childhood vaccines.63
Progress is already being made in some
states to increase pharmacists’ abilities to
administer vaccines. For example, in 2015,
Pennsylvania changed the age restriction
from age 18 to allow children as young as nine
to receive the flu vaccine in pharmacies.64
Additionally, in March 2016, Idaho lowered its
age limit from 12 to 6 to allow more children
to receive all recommended vaccines in the
pharmacy setting.65 Similar state legislative
efforts should be made across the country to
improve access to vaccinations for difficult
to reach populations. However, successful
implementation of this approach calls for a
strong immunization information system
in order to maintain current records of an
Many parents interact with individual’s immunization status when
pharmacists on a more regular basis receiving vaccines from multiple providers.
than with a primary health care
provider. Allowing pharmacists to
provide vaccines in a location that
is often more convenient than a
providers’ office has been shown to
increase immunization rates.
EVIDENCE TO ACTION BRIEF | SPRING 2017 15CONCLUSION
Vaccines are one of the most important
public health accomplishments in history.
Unfortunately, we are beginning to see
more outbreaks of preventable diseases as a
result of inadequate vaccination rates due to
vaccine hesitancy.
Misinformation, misguided fear and sometimes even
simple complacency can lead parents to delay or refuse
vaccinations for their children. State policies that make
access to immunization services challenging or make it
easy for parents to opt-out of vaccination programs foster
vaccine hesitancy, can result in low community vaccination
rates and increase the likelihood of disease outbreaks.
Stakeholders at all levels must take action to help
reduce vaccine hesitancy, optimize access and increase
vaccination rates to levels that will protect entire
populations—including those who are too young or have
another medical contraindication that prevents them
from receiving vaccines.
16 ADDRESSING VACCINE HESITANCY TO PROTECT CHILDREN & COMMUNITIES AGAINST PREVENTABLE DISEASESWHAT STAKEHOLDERS
CAN DO
TO ENCOUR AGE Combining and scaling up
these best practices can help
ensure that current and future
generations of children and
VACCINATION adults will continue to see the
benefits of vaccines.
Health care networks Providers can make use Health plans and insurers can
and educators can work of available tools and support provider efforts by
to ensure providers have training to understand adequately reimbursing for
the training and support major vaccine concerns, the entire cost of vaccination,
they need to make strong and prepare themselves for including purchasing, storage,
vaccine recommendations tough conversations. counseling and administration.
and adequately address the
concerns of hesitant parents.
Federal legislators States can enforce existing State and local health
can work to encourage vaccine mandates, make it departments can help to
vaccination by allowing more difficult to obtain vaccine address each cause of
payers to use premium exemptions and allow vaccines vaccine hesitancy through
differentials within the to be given in more convenient targeted public awareness
parameters of the federal locations such as pharmacies. and education campaigns.
law that incentivize use
of the recommended
vaccine schedule.
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EVIDENCE TO ACTION BRIEF | SPRING 2017 19PolicyLab Evidence to Action briefs highlight PolicyLab
research and propose evidence-based local and national
policy solutions to advance child health and well-being.
The mission of PolicyLab at Children’s The Vaccine Education Center was launched
Hospital of Philadelphia is to achieve in October 2000 to provide accurate,
optimal child health and well-being by comprehensive and up-to-date information
informing program and policy changes about vaccines and the diseases they prevent.
through interdisciplinary research.
The Center seeks to dispel some of the common
Founded in 2008, PolicyLab is a Center of misconceptions and misinformation surrounding
Emphasis within the CHOP Research Institute, vaccines. The goal of our team is to communicate
one of the largest pediatric research institutes in the facts about each vaccine as well as how
the country. At PolicyLab, our experience caring vaccines are made, how and why vaccines work,
for children and families informs our “evidence to who recommends them, whether they are safe,
action” approach to improving children’s health. whether they are still necessary, and when they
should be given.
PolicyLab Vaccine Education Center
Children's Hospital of Philadelphia Children’s Hospital of Philadelphia
3401 Civic Center Boulevard 3615 Civic Center Boulevard
CHOP North, Room 1528 ARC 1202
Philadelphia, PA 19104 Philadelphia, PA 19104
P 267-426-5300 P 215-590-9990
F 267-426-0380 F 215-590-2025
PolicyLab@email.chop.edu vacinfo@email.chop.edu
policylab.chop.edu chop.edu/centers-programs/
vaccine-education-center
@PolicyLabCHOPYou can also read
